Language, Interaction and Frontotemporal Dementia represents a wonderful example of neuroanthropological research, mixing together insights from neurology, linguistics and anthropology to examine a specific problem, and doing ethnographic research that is informed by ideas about how neural functions shape language use, social interactions and this particular type of dementia. I also deeply appreciate the mix of theoretical and applied work.

Here is a description of the book, cobbled together from the back cover and Amazon description:

In this volume, the researchers focus on the interactions of frontotemporal dementia (FTD) patients. These patients have right hemisphere, frontal and temporal pole atrophy which leaves their cognitive abilities intact, but their social interactions impaired and their personalities changed.

The description of FTD as a pathological change in social behavior provides the motivation in this volume to apply ethnomethodological and conversation analytic approaches to the organization of patients’ interactions. These approaches do more than document the disease and its effects on loved ones by revealing phenomena that can be analyzed empirically as causing systematic changes in the patients’ social interactions.

The volume opens with a discussion of the frontal lobes and their expected involvement in language use and social interaction. Then a conversation analytic approach is applied to analyze what changes in the structure of interaction lead to a sense that the interactions are impaired or inappropriate. Finally, the volume ends with a look forward to what FTD contributes to our understanding of human sociality and what has been gained in our understanding of the brain and language.

In the rest of this post, I want to do two things: explain some more what frontotemporal dementia is, and examine what the authors mean by “reverse engineering the social mind.”

Frontotemporal Dementia

In their introduction, Smith, Mates and Mikesell describe FTD as a heterogeneous clinical phenomenon, due largely to atrophy in the prefrontal and anterior temporal cortices. It accounts for about 4% of all degenerative dementias, and 20-25% of early-onset dementias.

FTD has three main variants: behavioral, semantic, and progressive nonfluent aphasia. The semantic type includes a loss of vocabulary and concepts; in other words, a loss of meaning. The aphasia group has troubles with the articulation and syntax of language, but can still understand words. The behavioral type is the most common and also most diverse: these individuals can have decreased affect, repetitive behaviors, worsening personal conduct, and reduced ability to handle complex, planned activities or skills.

The book largely focuses on the behavioral variant (bvFTD). The authors all highlight that FTD is often hard to recognize clinically: “FTD often presents with behaviors similar to psychiatric disorders, affective disorders, antisocial or aggressive behavior, as well as the prevalence of alcohol abuse (7).” Clinical diagnosis can also be difficult because most clinical tasks are cognitive assessments, and on which bvFTD patients often perform normally. bvFTD patients present behavior changes, not cognitive ones.

These changes fall into two domains: (1) abnormalities in social emotions and perceptions, and (2) changes in behavioral engagement. These changes are linked to atrophy in a range of brain structures. Early on, the frontoinsular, orbitofrontal and ventromedial cortices and anterior cingulate can be affected. As the dementia progresses, the right frontal cortex can show general atrophy in the ventral, medial, and dorsolateral prefrontal cortex, along with the temporal lobes, anterior cingulate, and insula.

With social emotions and perceptions, patients are “often seen as lacking social emotions like sympathy, empathy, shame, or guilt… Patients [can have a] lack of insight (i.e., unawareness of their behavioral changes) and lack of concern for others. Because of this ignorance, patients rarely self-refer to a physician (7-8).”

The slow distortion in the individual’s character and social conduct is captured in the Neary criteria (Neary et al. 1998, see Appendix A) as “early decline in social interpersonal and personal conduct,” “loss of sympathy or empathy,” “disinhibited speech and gestures, and violations of interpersonal space,” and “loss of emotional warmth, empathy, sympathy, and indifference to others.” These features, however, also co-occur with the individual’s growing lack of insight into his or her changing behavior or others’ reactions to those changes (10).

On the behavioral side, patients can “develop stereotyped behaviors from simple physical and verbal repetitions to complex routines, as well as alterations in eating habits such as gluttony or preference for sweets…. Patients either become indifferent, disinhibited, hyperactive, and gregarious, or conversely, grow apathetic, abulic (lacking initiative), and emotionally blunted (8-9).”

bvFTD patients often go through dramatic behavioral changes:

‘teetotalers’ beginning to abuse alcohol, some patients becoming verbally abusive in public, others losing social propriety and urinating in public or getting into traffic accidents without concern, shoplifting, giving away large amounts of money to strangers, and other odd or aberrant behaviors (11).

So some examples: Alan Fiske describes “Ned,” who was a driven and self-disciplined man who then “stopped working out, gained a lot of weight, and played golf instead of going to work at his management job. So he was fired… [and] his wife divorced him. But while this is happening, patients continue to be ‘rational’: during the early stages of the disease their cognitive and perceptual skills remain largely intact, they generally recognize what others think and feel, and they understand the consequences of their actions (200).”

Mates speaks of her informant Romeo:

The Romeo I met was a shadow of his former self. Yes, he did laugh on occasion, and he certainly watched hours of cable news, but he now had to be directed to engage in almost all activities other than getting food or going to the bathroom. Whey they went to church services, [he and his wife Juliet] no longer discussed the merits of the sermon in the car on the way home like they used to. The man who used to take it upon himself to take care of many household chores could not be relied on to water the plants without supervision (3).

My second participant-observation ethnography visit with 62 year old Romeo [was]… to look over some of his photographs with him as we put together a scrapbook. Instead of the warm interaction, I was hoping for, I found the experience to be not only affectively flat, but even alienating. About a picture with people not previously presented, he said only, This is Warren and Carrie, without further explanation. Later commenting on another photograph he explained too much saying, This is my wife Juliet. This particular instance really struck me as strange and inappropriate because she was not a stranger to me (139).

Reverse Engineering the Social Mind

What do the authors mean by reverse engineering?

Reverse engineering starts with an actual product, which is then broken down into its components parts. How those parts are manufactured and put together to create the final product is the main goal of reverse engineering. This is the explicit sense that all the authors bring to the volume.

All the authors emphasize two things:

-The ethnographic reality, the final “product” of our lives, is the main focus of the research

-The researchers try to break down the different components that make up that product, in this case the problem of frontotemporal dementia

The reality, from the introduction:

Our approach to research into social interaction is also to emphasize the “final product” – actual behaviors – and how people actually interact while using the brain they have that day at that moment… We take then social interaction as the beginning and core of our analyses…

The utterly empirical nature of this research, its subject, and what it can provide for those interested in the brain, mental illness, language, and social interaction, is a powerful and unique contribution that this work makes. If we have accomplished our most simple objective – to show and describe the events and actions occurring in the data in accordance with how the actual interactants treated them – we have presented a description of reality that embeds a clinico-pathology in social interaction (13-14)

The processes. A good example here is what Salvatore Torisi writes:

People regulate their actions in social contexts. A typical interaction between two individuals may require such disparate regulatory skills as deciding when or how to phrase an utterance, whether or not to delay or stifle an inappropriate impulse, or modify a behavior to match what is prosocial and helpful for another…

In this chapter, social regulation is construed not as a single psychological construct but involves a number of different cognitive and emotional processes… Some of these processes are predicated on the perception and monitoring of one’s self. Other processes are predicated on the other individual in a social dyad, such as considering or imagining what the other knows or may be thinking. Such processes are often referred to as having “theory of mind” (Premack and Woodruff 1978). And still other processes are predicated on socially-relevant emotions that arise when interacting with others.

All these processes can be thought to exist against a backdrop of learned declarative knowledge and cultural rules for what one should or should not do in a social context (23).

Some authors also include the idea of how something gets “manufactured” or put together.

-Understanding the original engineering, or how specific components come to be and how they work together. In this case, the authors often draw on human evolution. Other perspectives could be included, such as the neurological process of atrophy or a developmental perspective on how people come to have social minds and interact in social contexts (in other words, pick your theory!)

Here is a quote from the introduction.

Social interaction [is] the primordial site that the homo sapien brain has evolved in and evolved for and to which all theories of social functioning whether neurological, psychological, or linguistic must ultimately be held accountable (14).

Alan Fiske goes into greater length on this theme.

Humans, like all organisms, require proximal motivational representations of their adaptive and functional needs. These motives must be given determinate form by cultural transmission, individual experience, and social processes. Humans depend on social relations to live and prosper, so social relationships must be among their fundamental goals and reinforcers. This is what social motives and moral emotions are…

Social emotions are proximate motivational signals of the adaptive, cultural or personal value of relationships. FTD patients lack these motivational proxies for the long-term value of relationships; they don’t experience moral emotions or social needs (232).

In these efforts, as well as their interdisciplinary approach and their multiple methods, the authors of this volume illustrate what Greg and I call for when we speak of neuroanthropology. We might differ in some particulars. They have more emphasis on linguistics and on evolution, we emphasize more anthropology and neural plasticity. But I find it heartening that this type of work is popping up sui generis in different places. It bodes well for the future.

And for me personally as a scholar, this work has set off some intriguing notions for my own research as a neuroanthropologist. I have focused for a long time on behavioral engagement and motivation. This work opens up the social side for me in ways I hadn’t considered, but are obviously part of what substance users, video game players, and soldiers deal with as they manage the problems they have and the social lives they live.

Andrea Mates sent me an email which also provides some great additional insight into their work and the book:

“One of the features of frontotemporal dementia (FTD) is that people affected by it lack insight into their condition, so doctors depend on their caregivers to provide reports of changes in behavior. And the changes they expect to hear are reports of inappropriate or unexpected social behaviors. As a team of linguists and anthropologists, we spent time with several families for as long as two years. We accompanied them during their everyday activities and routines, taking fields notes and making audio and video recordings. For most of the families, this involved being with them for 3-4 hours in one location such as in their home or sometimes in some institutional facility like an adult day care. A few times we went out with them to some place like a park or a drug store.

In contrast to what we had heard from the clinicians, we did not normally experience gross violations of social norms. (We had heard about patients loudly asking about other people’s sexual orientation, compulsively shopping, and watching countless hours of porn while a loved one battled cancer.) Instead, the ethnographers reported a death by a thousand paper cuts and here the linguists’ training in conversation analysis became very useful. Conversation analysis is concerned about how interactions are managed by all participants, and the basic unit of analysis is the “adjacency pair”, an interactional move like a turn of talk that creates social pressures and expectations for a particular kind of second move. At this level of analysis, we were better able to characterize the social deficits that were impacting their relationships as well as the abilities they continued to maintain.

For example, in his chapter, Smith’s analysis shows that FTD patients may not conform to social expectations for being an engaged participant of an ongoing conversation. Then he examined different ways in which the other participants manipulated the interaction to manage this lack of conformity.

Joaquin’s chapter mapped the structure of interactions between caregivers and children against those between caregivers and FTD patients. She argues, among other things, that both these populations have prefrontal cortices that are at less than full capacity and that similarities between the interactions support the notion that the prefrontal cortex mediates appropriate social behavior.”

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Neuroanthropology. Sometimes it’s straight-up neuroscience, sometimes it’s all anthropology, most of the time it’s somewhere in the middle. Greg is the cultural guy, now interested in bio stuff. Daniel is the bio guy, now interested in cultural stuff. Or, to say it differently, Greg does capoiera, mixed martial arts, and rugby. Daniel does alcohol, drugs, and video games. Two very different styles of recreation.